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Management Brief No. 149

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Management eBriefs
Issue 149March 2019

The report is a product of the VA/HSR Evidence Synthesis Program.

Scaling Beyond Early Adopters: A Systematic Review and Key Informant Perspectives

The process of moving research insights into clinical practice can be slow and a gap often remains between best practices – frequently developed within single sites or small populations – and general practice delivered at a population scale. The field of implementation science seeks to mend this gap by promoting the adoption and appropriate use of effective interventions, practices, and programs, which includes the study of scale-up and spread of innovations. While hard-to-engage sites may have unique characteristics from sites that are engaged quickly or earlier, they are not typically differentiated in scale-up and spread processes. Thus, there is a lack of information about hard-to-engage sites and how to tailor approaches to these sites in scale-up and spread efforts.

Scale-up and spread refers to "deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects, so as to benefit more people and to foster policy and program development on a lasting basis."

The objective of this systematic review conducted by investigators with VA’s Evidence-based Synthesis Program (ESP) Center in Los Angeles, CA is to understand strategies that are available to scale-up and spread clinical and administrative practices across large healthcare systems such as VA, with a focus on "hard-to-engage" sites. After screening close to 2,000 citations, investigators reviewed the full text for 307 publications and included 52 publications in this review.

In addition to the literature review, investigators invited 24 key stakeholders to participate in semi-structured interviews. These interviewees were drawn from two distinct samples: project leads on scale-up or spread initiatives, and improvers on VA’s quality metrics. Project lead interviewees shared their perspectives on and experiences with strategies to scale-up and spread clinical and administrative practices across healthcare systems, with a focus on "hard-to-engage" sites. Interviewees who were drawn from sites demonstrating improvement in VA’s performance metric system, which combines a multitude of individual metrics to produce an overall global score for each VA facility, shared perspectives on and experiences with strategies their sites used to improve their overall score, as well as any specific metrics that may have been targeted for improvement. Investigators drew from both the key informant interviews and the literature for their findings.

Conclusions and recommendations for future scale-up or spread efforts
Low-performers and hard-to-engage audiences are most in need of engagement when spreading innovations intended to standardize practice or improve quality of care, but they were under-studied in the identified literature on large-magnitude scale-up and spread efforts. Variations in care delivery will require a better understanding of how to work with low-performer and hard-to-engage groups. Hard-to-engage sites can be highly variable in terms of the challenges or barriers they face. For these myriad of individual factors, bundles of engagement strategies that are more personalized and intensive can help spread initiators reach these groups. More testing of strategies to use with these groups, as well as documentation of adaptations or tailoring large spread efforts to engage different groups of adopters, is needed. In summary, recommendations for future work in implementing scale-up or spread efforts include:

  • Before engaging sites, take time to understand the salient local factors (i.e., authority to make necessary changes, necessary resources) and determine if there are existing networks that could be leveraged (i.e., peer-to-peer, VA hubs).
  • In organizing a spread or scale-up effort, consider the various models infrastructure could take and how these may impact the effort.
  • Using the knowledge of local sites that has been gathered, identify potential challenges or characteristics of these sites that might make them hard-to-engage and tailor strategies appropriately.

Future research
Future work moving from the early stages of scale-up and spread into a more detailed description of the full spread phase could focus on testing different strategies for large magnitude spread – and for reaching hard-to-engage sites, in particular. This effort also could include better documentation of tailoring or adaptations that occur towards later stages of spread efforts, including specific approaches and strategies used to engage hard-to-engage sites.

In addition, defining the overlap between low-performing and late-adopting or hard-to-engage adopters would aid in better tailoring strategies for both groups. While there may be substantial overlap, some distinctions were also made. For instance, high-performing sites may be hard to engage if they do not have a need for the intervention, and low-performing sites, in contrast, may have needs that align with an intervention and, thus, may be eager to engage. This work could be done both empirically, but also conceptually.

Miake-Lye IM, Mak SS, Lambert-Kerzner AC, Lam CA, Delevan DM, Secada PM, Beroes-Severin JM, Olmos-Ochoa TT, Shekelle PG. Scaling Beyond Early Adopters: A Systematic Review and Key Informant Perspectives. VA ESP Project #05-226; 2019.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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